Field Visit: Highlights from Local Programs · 2019-02-19 · 7/20/2017 1 Field Visit: Highlights...

7/20/2017

1

Field Visit: Highlights from Local Programs

July 20, 2017

CDC Site Visit

Session Overview• Healthy Parks, Healthy People

• Angela Pease, Maryland Department of Natural Resources• Laura Patrick, RN, Caroline County Health Department

• Somerset Trail Mix• Clint Sterling, Somerset County Parks and Rec

• Healthiest Maryland Businesses• Nicole Morris, MS, RN, CWWPM, Kent County Health Department• Jennifer Johnson, CWWS, Wicomico County Health Department

• Nutrition Programs• Rena Brooks, Food Supplement Nutrition Education

Kat Gunby, MPH, Worcester County Health Department

• Diabetes Prevention Program in Somerset County• Crystal Bell, MPA, Somerset County Health Department

• Diabetes Prevention Program in Dorchester County• Ashyrra C. Dotson, Associated Black Charities

• Health Systems Integration with Primary Care• Angela Mercier and Miranda LeCompte, Dorchester County Health Department

7/20/2017

2

Healthy Parks, Healthy People

Angela Pease, Maryland Department of Natural Resources

Laura Patrick, RN, Caroline County Health Department

7/20/2017

3

Grant Deliverables‐Program Development

7/20/2017

4

Program Tracking and Evaluation

7/20/2017

5

Successes!

7/20/2017

6

Contact Information: Angela Pease

Maryland Park Service Interpretive Planner

[email protected]

410‐260‐8150

A Local Collaboration With Our

Local State Parks & FQHC-Choptank Community Health System-Denton Maryland

12

7/20/2017

7

Getting Started: Our Story

1. Our local Park Ranger-Jessica stopped into our Wellness Office for work with our tobacco cessation program

2. Maryland DHMH had asked local 1422 Coordinator’s to look at places our community members could walk

WIN-WIN Situation

13

Getting Started: Our Story

3. Kayla Zalcgendler-DHMH put Laura local 1422 Coordinator in touch with Meghan Ames-DHMH on Healthy Parks/Healthy People

4. Jessica with our local Martinak and Tuckahoe State Parks very interested in program and was in contact with Angie at DNR at State

5. First meeting of all parties held July 20th 2016

THE BEGINNING OF A GREAT PROGRAM STARTED!!!!!!

14

7/20/2017

8

First Partner Meeting – July 20, 2016

Met at Martinak State Park Partners present◦ Department of Natural

Resources

◦ Martinak State Park

◦ Caroline County Health Department

◦ Maryland Department of Health

Agenda items1. Welcome and Introductions

2. Healthy Parks, Healthy People Overview

3. Opportunities in Caroline County

4. Roles, Responsibilities, and Work Plan

5. Wrap-up and Next Steps

15

Meeting Local FQHC

Local Health Department very fortunate to have a very good working relationship with our FQHC: Choptank Community Health System◦ Choptank receives funding from our 1422 grant to work on EHR

software to identify patients who have prediabetes and pre-hypertension.

Appointment was made with Susan Johnson, VP of Quality and Population Health in August, 2016.◦ Susan felt that local provider’s would be in great favor of the

program since they wanted their patients to engage in more physical activity.

16

7/20/2017

9

Partner Conference Call – Sep. 7, 2016Agenda:1. Call with FQHC-Laura2. Brochure development-Angie

and Laura3. Print Material-Poster’s-Angie4. Budget-Meghan5. Intern-Jessica

Results of Call Laura to work with FQHC-

Choptank on date for Kick-Off event

Angie to have graphic designer add Martinak and Tuckahoe State Parks to brochure and poster’s

Meghan checking on cost of food for event

Jessica to hire new intern to start planning events for HPHP program

17

18

7/20/2017

10

19

Work With Local High School

Caroline County Health Department also included High School Occupational Health Students in our HPHP work.

Students made a display board to put up at the park and worked on a bulletin board at the park, which was completed in Nov., 2016.

20

7/20/2017

11

Work with FQHC-CCHS Continues Susan Johnson verified that

CMO of CCHS Dr. Moss approved-December 2016

Choptank getting new EHR software and working on incorporating HPHP program into referral system

Date picked for Kick-Off Event April 19th 2017-Tuckahoe Park

Work plan until Kick-Off in April

Laura to get invitations printed Jessica and Heather (intern) to

plan activities for the Launch and for activities to start now at the Park-See next slide for December calendar made by Heather

Angie to print posters for Kick-Off Event

Meghan to coordinate all conference calls and meeting

21

Goal: Increase those using parks

22

Healthy Parks, Healthy People is launching in Martinak and Tuckahoe State Parks.

Medical providers are invited to come experience first-hand how this program can help your patients improve their health and well-being in Maryland’s

great outdoors.

7/20/2017

12

23

24

Jessica and Heather doing Great job at planning activities at the Parks!

7/20/2017

13

25

Caroline County FQHC Quick Facts Choptank Community Health System, Inc. 7 Health Center Site Locations 9 School-Based Health Centers 32 School-Based Dental Sites 4 Migrant Health Sites Serving 26,504 Patients 17% Uninsured 40% Medicaid 7% Medicare Employing 150 Staff Members

26

7/20/2017

14

Collaboration with CCHS for April Launch of Healthy Parks, Healthy People Well-centive Software having some delays but CCHS

provider’s want to move forward Monthly calls with CCHS Susan Johnson has 10 staff from CCHS to attend April

19th Launch

27

Planning for the Kick-Off Event

March conference call to finalize agenda

Invitation list finalized and invitations mailed out

Funding for food secured from Friends of MartinakGroup Foundation

28

7/20/2017

15

Healthy Parks, Healthy People Kick-Off Event –April 19, 2017

29

Healthy Parks, Healthy People is launching in Martinak and Tuckahoe State Parks.

Medical providers are invited to come experience first-hand how this program can help your patients improve their health and well-being in Maryland’s

great outdoors.

Kick-Off Event –April 19, 2017

30

Angie and Laura Presenting at April 19th 2017 Launch Healthy Parks/Healthy People

7/20/2017

16

Kick-Off Event –April 19, 2017

31

Choptank Community Health staff talking with Martinak Friends Foundation President about all the park has to offer

Where we are today with HPHP

32

A lot of advertising has been done for the program. Please see our Big banner we brought with us today and please take a brochure that we just had printed.

Referral Form to Enroll in ProgramPatient Name____________________________________The patient is being referred to the Healthy Parks, Healthy People program. Physician Signature________________________________Date : ________________________________Local Parks participating:Martinak State Park Tuckahoe State Park

410‐820‐1668 410‐820‐1668Harriet Tubman Underground Railroad National Park

410‐221‐2290

7/20/2017

17

Laura’s Contact Information

33

Laura Patrick RN, MSChronic Disease Coordinator

403 S. 7th Street Denton, MD 21629Phone: 410-479-8080Fax: 410-479-2014E-mail: [email protected]

Somerset Trail MixClint Sterling

Somerset County Rec and Parks

34

7/20/2017

18

Somerset County Recreation and ParksClint Sterling

Creating Walkable Communities through community partnershipsCDC1422 Grant

A little about us….

7/20/2017

19

Somerset County

Somerset County is the southernmost county in the U.S. state of Maryland. As of the 2010 census, the population was 26,470. making it the second-least populous county in Maryland. The county seat is Princess Anne.

Founded: 1666 Population: 25,928 (2016) Area: 610 sq miles (1,580 km²) County seat: Princess Anne Colleges and universities: University of Maryland Eastern

Shore Points of interest: Whitehaven, Maryland · Somers Cove

Marina

Our CanvasAbundant open spaceRural roadsWater AccessCounty Parks and Golf CourseJane’s Island State Park

7/20/2017

20

Here’s what we came up with….

Somerset County Trail Mix

Made possible with funding from the Centers of Disease Control and Prevention.http://www.cdc.gov

Made Possible with Funding from Centers for Disease Control and Preventionhttp://www.somersettrailmix.com/

7/20/2017

21

7/20/2017

22

7/20/2017

23

7/20/2017

24

7/20/2017

25

7/20/2017

26

7/20/2017

27

7/20/2017

28

Healthiest Maryland Businesses

Nicole Morris, MS, RN, CWWPM, Kent County Health Department

Jennifer Johnson, CWWS, Wicomico County Health Department

Maryland

Nicole Morris, MS, RN, CWWPMHealthiest Maryland Businesses Regional Lead, Mid/Upper Shore

Work@Health Certified Trainer

7/20/2017

29

www.healthiestmdbusinesses.org

Work@Health® Project Overview

Funded through the Affordable Care Act’s Prevention and Public Health Fund under the direction of the Centers for Disease Control and Prevention (CDC)

Develop and deliver a worksite health training program to employers and wellness professionals

Accelerate the adoption of science and practice-based, comprehensive worksite health programs nationwide

Help to identify, develop, and share best practice models for comprehensive worksite health program training


Timeline

•Work@Health Pilot•November 2013

•Train the Trainer (T3)•April- November 2014

•Certified Trainer•November 2014-Present


7/20/2017

30

www.healthiestmdbusinesses.orgwww.healthiestmdbusinesses.org


7/20/2017

31


Reach

•12 workshops•80 businesses

•92,984 employees


Workshops Across MD


7/20/2017

32


Regional Distribution



Size Distribution

Very small <100, Small 100-249, Medium 250-749, Large ≥750


7/20/2017

33


City of Greenbelt

•“As Recreation Director for the City of Greenbelt, and an advocate of health and wellness for our employees, I feel the workshop was extremely informative and well presented. I am grateful to have a another resource to work with and I will be calling on Healthiest Maryland Businesses for assistance as the city expands our employee wellness programs.” •-Julie McHale



Arc of Washington County

•“Work@Health was the best and most comprehensive training I’ve ever attended about worksite wellness. I highly recommend this training for anyone involved in workplace wellness, whether they are just getting started or trying to figure out what to do next.”

•-Janis Williamson


7/20/2017

34


Participant responsibilities

Complete the Work@Health® employer training Establish a health promotion committee Plan/implement the Work@Health® core elements Grow their program Participate in periodic surveys Help create and grow peer-learning community

•Hand-off to Regional Coordinator (and Local 1422 if available)



7/20/2017

35


Contact:

•Nicole Morris, MS, RN, CWWP•Regional Lead, Mid/Upper Eastern Shore•410‐778‐2533•[email protected]



Perdue FarmsJennifer Johnson, CWWS

1422 Coordinator and HMB Lower Shore Regional Coordinator

Wicomico County Health Department

7/20/2017

36


Company Overview

•Poultry company

•Over 20,000 employees in different states

•2,500 employees in Wicomico Co.

•Started relationship in 2013 with smoking cessation classes


History with HMB

•Became an HMB in 2015

•Attended the Work@Health Training in 2015

•Received 1422 funding to write wellness policies

•Created 3 policies for wellness team, physical activity, and nutrition

7/20/2017

37


Wellness Team

•Meets monthly to discuss wellness for employees (new topic each month)

•Health risk assessments, measure biometric screenings, Lipid, and A1C on all HIP staff

•On site clinics


Physical Activity

•Marked walking trail

•Walking during breaks/lunch

•Walking meetings when possible

•HIP specialists can help set activity goals, track progress, and educate on different activities

7/20/2017

38



Physical Activity Continued

•Received $2,500 from state 2016 Physical Activity mini grant

•Used to enhance on site gym at corporate office

•Under desk pedal exerciser, dumbbells, resistance bands, yoga chairs, posters, printed map of walking path, yoga ball, mat, and DVD

•Adopted two policies•Exercise room policy

•Walking policy

7/20/2017

39



Nutrition

•All locations with cafeterias have Myplate posters and portion size posters

•All work meetings have healthy options: fruits, veggies, water and low sodium foods

•Vending machines be labeled with healthier food options

7/20/2017

40


Diabetes Prevention Program

•Did online Omada program•Over 200 signed up

•WiCHD to start on site class Aug. 2


Awards/Recognition

•Wellness at Work awards: GOLD last year and this year

•Helped promote HMB in commercial on WBOC

7/20/2017

41


Healthiest Maryland Businesses: Perdue FarmsJennifer Johnson, CWWS

1422 Coordinator and HMB Lower Shore Regional Coordinator

Wicomico County Health Department


Company Overview

•Poultry company

•Over 20,000 employees in different states

•2,500 employees in Wicomico Co.

•Started relationship in 2013 with smoking cessation classes

7/20/2017

42


History with HMB

•Became an HMB in 2015

•Received 1422 funding to write wellness policies

•Created 3 policies for wellness team, physical activity, and nutrition


Wellness Team

•Meets monthly to discuss wellness for employees (new topic each month)

•Health risk assessments, measure biometric screenings, Lipid, and A1C on all HIP staff

•On site clinics

7/20/2017

43


Physical Activity

•Marked walking trail

•Walking during breaks/lunch

•Walking meetings when possible

•HIP specialists can help set activity goals, track progress, and educate on different activities

Where the healthiest choice is easy

7/20/2017

44

Where the healthiest choice is easy


Physical Activity Continued

•Received $2,500 from state 2016 Physical Activity mini grant

•Used to enhance on site gym at corporate office

•Under desk pedal exerciser, dumbbells, resistance bands, yoga chairs, posters, printed map of walking path, yoga ball, mat, and DVD

•Exercise room policy

7/20/2017

45


Nutrition

•All locations with cafeterias have Myplate posters and portion size posters

•All work meetings have healthy options: fruits, veggies, water and low sodium foods

•Vending machines be labeled with healthier food options


DPP

•Did online Omada program•Over 200 signed up

•WiCHD to start on site class Aug. 2

7/20/2017

46


Awards/Recognition

•Wellness at Work awards: GOLD last year and this year

•Helped promote HMB in commercial on WBOC

Nutrition ProgramsRena Brooks, Food Supplement Nutrition Education

Kat Gunby, MPH, Worcester County Health Department

7/20/2017

47

WELCOME

Rena Brooks, Eastern Region Faculty Assistant, University of Maryland – Extension

Food Supplement Nutrition Education (FSNE)Maryland’s SNAP‐Ed Program

1422 Food Assistance Site Initiative (Securing Food Resources for Families)

Grant 1422 – MDH & CDC

The purpose is to provide nutrition education to food insecure families in the five lower shore counties in an effort to promote healthier lifestyles and reduce chronic diseases.– Dorchester– Caroline– Worcester– Wicomico– Somerset

7/20/2017

48

Building Partnerships

22 organizations utilizing the Market to Mealtime materials

• 19 Pantries

– Faith Based/Churches, Shelters, Non‐profit Resource Centers

• 3 Local Health Departments

–Caroline, Dorchester, Worchester

Food Assistance and Nutrition Education – A Perfect Pair!

• Food insecure families benefit in many ways:

– Increase knowledge about healthy foods

– Utilize food shares more fully, wisely

– Increase skills (nutrition and food safety)to prepare family meals, including fruits and vegetables

– Increase likelihood of healthy behavior change

7/20/2017

49

Nutrition Education Materials

‐ Seasonal Poster Displays

‐ M2M Volunteer Button

‐ Seasonal Recipe Cards

‐ Seasonal Handouts

‐ DHR Flyers

‐ Targeted Donations Flyer

‐ Two Hour Training

‐ Referral information:

Eatsmart.umd.eduHealthy Habits and Smart Shopping TipsEatfreshmaryland.orgEBT/WIC/FMNP redemption at Farmers’ Markets

7/20/2017

50

3‐Panel Poster Display

Seasonal Recipes

Recipes correspond with seasonal produce

featured in each poster display

7/20/2017

51

2-sided handout with tips to take home

Folds in half like a booklet

Targeted Donations

7/20/2017

52

Market to Mealtime Nutrition Education materials allows us to:

• Pair Market to Mealtime seasonal recipes with foods being distributed in food packages

• Provide nutrition information and healthy recipes, including fruits and vegetables, for participants to try at home.

• Showcase lobby displays, share information, engage participants in nutrition dialogue to encourage healthy choices

Food Assistance Site Data

• 98% of participants said the display posters would influence what they took home that day.

• 77% of participants said they planned on taking home a new fruit or vegetable that day.

• 87% of participants said they would involve family in preparing the fruits or vegetables.

7/20/2017

53

Successes• In one year, one the eastern Shore alone, we

have held 10 trainings and were able to partner with 19 pantries.

• Pantry staff look forward to receiving and distributing our materials.

• Pantry staff look forward to attending meeting, training, and sharing their implementation strategies.

• In this grant year, during the first three quarters, we have distributed approximately 46,900 pieces of nutrition education literature to nearly 15,600 food insecure families.

Challenges

• Rural Area

– Limited number of pantries in rural areas.

– Pantry providers are volunteer and time is limited. Affects training and willingness to commit.

– Pantries are supported by small, local churches and cannot support the delivery fees.

– Transportation for pantry clients is not always available.

– Data collection can be a challenge.

7/20/2017

54

Thank you!

Rena BrooksEmail: [email protected]

Phone: (410) 228‐8800

Cell: (443) 518‐9576

NUTRITION EFFORTSKAT GUNBY, MPH, DIRECTOR OF PREVENTIONWORCESTER COUNTY HEALTH DEPARTMENT

SNOW HILL, MD

7/20/2017

55

ABOUT WORCESTER▪ Location: Rural Lower Eastern Shore; bordered by Atlantic Ocean, Delaware, Virginia. Low population density, widespread geographic area with three population centers and significant farming and forestry.

▪ Top economic industries: Agriculture, Tourism, Hospitality.

▪ Average annual population ~51,000; sky rockets with Ocean City tourism to as many as 400,000 on any given weekend May – September.

ABOUT WORCESTER COUNTY HEALTH DEPARTMENT▪ Public Health Accreditation since January 2014.

▪ Prevention Services Unit:

▪ Alcohol and Other Drug Prevention

▪ Cancer Screening/Prevention

▪ Tobacco Prevention

▪ Chronic Disease Prevention

▪ Chronic Disease Highlights:

▪ Seeking recognition for National Diabetes Prevention Program.

▪ Lifestyle Balance since 2008, state spokesperson Eddie Carmean

▪ Just Walk – 2017 20th Anniversary

▪ Healthy Maryland Businesses

▪ Hypertension Initiative

7/20/2017

56

CHRONIC DISEASE BURDEN AND DEMOGRAPHICS▪ Prevalence of diabetes among adults: 16.7% vs. state average 10.2%.

▪ Percent of obese adults: 31.1% vs. state average 28.5%.

▪ Percent of adults at healthy weight: 34% vs. state average 31.1%.

▪ High blood pressure among adults: 36.7% vs. state 32.8%.

▪ Prevalence of heart disease among adults: 16.7% vs. 7.5% state average.

▪ No leisure‐time physical activity among adults: 27.4% vs. 23.2% state average.

Source: 2012‐2014 Maryland BRFSS *Three year moving average

GRANT ACTIVITIES: NUTRITION AND FOOD BANKS▪ Billing for medical nutrition therapy provided by LHD registered dietitian. Approximately 25 referrals in first year.

▪ Monthly grocery store tours –participation on the rise.

▪ A convenient food retailer – Uncle Willie’s – agreed to work with LHD on increasing healthier food choices.

▪ Market to Mealtime partnership with all food pantries in the county. Provides recipes, resources, nutritional guides.

▪ Ongoing outreach and educational presentations via early learning centers and churches, especially African‐American churches.

7/20/2017

57

LIFESTYLE BALANCE GIRDLETREE

TOOLS, RESOURCES, MATERIALS DEVELOPED▪ Nutrition Tips and Fitness Bits monthly YouTube series features HMBs and our registered dietitian.

▪ Local, Fresh, Delicious pamphlets highlighting farmers’ markets and distributed throughout Somerset, Wicomico and Worcester counties. Revised and re‐printed this year.

▪ Tri County Diabetes Alliance – website and Facebook Page – revamp this year.

7/20/2017

58

CHALLENGES▪ Rural, food desert

▪ Low income, low education

▪ High rates of chronic disease

▪ Health Care Professional Shortage Area

▪ Medically Underserved Area

▪ Transportation Barriers

SOCIAL MEDIA: YOUTUBE▪ Fitness and Nutrition video: https://youtu.be/gV1flJ_zhLo

▪ Grocery Store Tour video: https://youtu.be/TNiRFj‐anx8

7/20/2017

59

WORCESTERKat Gunby, MPH

Director of Prevention

Diabetes Prevention Program in Somerset County

Crystal Bell, MPA

Somerset County Health Department

7/20/2017

60

Somerset County Health Department 1422 Grant Site Visit

Crystal Bell, MPA

DEMOGRAPHIC OVERVIEW

Somerset County is located on the Eastern Shore of Maryland

Population is 25,768

-54% White

-42.4% Black or African American

-3.5% Hispanic and 2.1% two or more races

Somerset County has the highest rate of poverty in the state, with 25.5% living below the poverty line and a per capita income of $16,748 (2015 United States Census Bureau).

7/20/2017

61

CHRONIC DISEASE BURDENS

Source: 2015 Census Data

Health Statistics Somerset Maryland County Ranking

Overall Mortality / 100,000 Population (Age-Adjusted)

946.6 793.5 2

Heart Disease Mortality / 100,000 Population (Age-Adjusted)

285.5 181.6 1

Diabetes Mortality / 100,000 Population (Age-Adjusted)

(U) 20.4 (U)

Rate of Obesity 37.22% 27.61% 2Rate of Diabetes 23.58% 10.39% 1

HEALTH RISK FACTORS

7/20/2017

62

1422 GRANT OBJECTIVES

Strategies to build support for lifestyle change for those at high risk of chronic disease health burdens

Environmental strategies to promote health and reinforce behaviors

Health System Interventions to improve quality of healthcare delivery to high priority population

Build community linkage strategies to support 1422 prevention efforts

INTRO TO 1422 GRANT

Initial Meeting With (LHIC) April 14, 2015

Health risk factors reviewed

County goals/objectives identified

7/20/2017

63

KEY PARTNERSMcCready Health

Peninsula Regional Medical Center

Chesapeake Healthcare (FQHC)

Somerset Recreation and Parks

Crisfield Clinic

Marion Pharmacy

Crisfield Pharmacy

BUILDING SUPPORT OF NDPP Face-to-face office visits

Effective communication/Continued support

Clear and concise understanding of NDPP

7/20/2017

64

BUILDING SUPPORT OF NDPP (CONT.)

Raising awareness (marketing/outreach)

Quarterly report updates/progress reports

Creation of Bi-directional referral system

Patient follow up letters

Effective program results

Positive feedback

IT’S ALL ABOUT TRUST &

COMMUNICATION!

Health System Interventions

Patients with risk factors for developing diabetes (A1c, family history, history of gestational diabetes, etc.—are flagged in the EHR system

Patients that have been identified are screened at their office visit using the tools LHD’s provided (CDC Risk Scorecard)

Nurse or provider gives the patient information (flyers, brochures, or website printouts) that highlight corresponding county DPP program information

If the patient agrees, FQHC has patient sign a HIPPA release and referral is sent through EHR , via fax to the appropriate county w/provider signature

7/20/2017

65

DEVELOPING AND IMPLEMENTING NDPP SYSTEMS

RESOURCES/MATERIALS

7/20/2017

66

Resources/Materials

Resources/Materials

7/20/2017

67

RESOURCES/MATERIALS

PARTNERSHIP AND SUPPORT

SCHD worked closely with community partners

Ensured all efforts aligned with 1422 and county objectives

Will continue partnerships and support for other collaborative programs

7/20/2017

68

CHALLENGES Expanding/Sustaining NDPP within County

Limited resources/venues

Increased referrals from (TLCCS)

Engagement of community to support lifestyle change programs

Raising awareness about prediabetes among community stakeholders

Pay for performance reimbursement model

SUCCESSESDevelopment of bi‐directional referral process

between community resources and health systems

Implementation of (6) DPP classes within county

Development of effective continued communication methods to recruit and support DPP

Increased worksite wellness initiatives

DPP program/participant success of 7% weight loss

Increased physical activity opportunities

7/20/2017

69

QUESTIONS?

Crystal Bell BA, MPA

Director of Prevention Services

Somerset County Health

Department

443-523-1760

[email protected]

Thank you!

Diabetes Prevention Program in Dorchester County

Ashyrra C. Dotson

Associated Black Charities

7/20/2017

70

139

Ashyrra C. Dotson, Director of ProgramsAssociated Black Charities - Dorchester County

140

AD1

AD1 Ashyrra Dotson, 9/29/2016

7/20/2017

71

To define the rural community, it’s demographics and the Health Needs

To demonstrate community engagement strategies for the inclusion of CHWs in National Diabetes Prevention Program

To address the benefits of the Community Health Worker influence on DPP education

To review the challenges surrounding successful inclusion of CHW’s and the Diabetes Prevention Program

141

142

?

7/20/2017

72

143

DPP - The need in Dorchester County

144

Hypertension

Diabetes

7/20/2017

73

145

CHWs and DPP in Dorchester County

• Utilized professionally trained, non-clinical, trusted community members as front line workers (Community Health Workers – CHW) to focus on connecting our community to the DPP (Diabetes Prevention Program)

• We met our community members where they were –and that meant where they live, work, pray or play

146

Meeting People Where They Are:

7/20/2017

74

147

CHWs and DPP in Dorchester County

• FINALLY – provide direct intervention to the community through the Diabetes Prevention Program with the Community Health Workers at little to often NO COST.

Rectifying participant concerns regarding privacy

Cost associated with this year long program

Maintaining interest and continuing effective engagement with the community

148

7/20/2017

75

149

DPP in Dorchester County - BENEFITS

Community Members, CHW’s and Health Care Providers connecting

Increased Access to the prominent Primary Care Facility

Emergency room utilization reduced for preventable Chronic Disease issues

Direct referrals

A restored sense of TRUST among program participants

CHW’s are now more inclusive as a part of the overall health care team

NO COST to program participants

TRANSACTIONAL & TRANSFORMATIVE CHANGE TRANSACTIONAL: Interventions that help individuals negotiate existing

structures and challenges TRANSFORMATIVE: Solutions that re-frame issues from a focus on

“problem individuals” or “problem groups of people” to the acknowledgement of how people are historically “differently placed”; A solutions-oriented focus on making systems and structures equitable.

150

7/20/2017

76

National Diabetes Prevention Program

National Diabetes Prevention Program

Cost-Sharing among Providers for Vulnerable Populations

Cost-Sharing among Providers for Vulnerable Populations

Communities Engaged in

longer term Self-Management

Behaviors

Communities Engaged in

longer term Self-Management

Behaviors

CHW providing services for the

community within the

Community

CHW providing services for the

community within the

Community

Support Team -Participant, CHW,

PCP and Resources and

Service Agencies

Support Team -Participant, CHW,

PCP and Resources and

Service Agencies

151

152

Resources

DHMH - Maryland Health Equity Datahttp://dhmh.maryland.gov/mhhd/Pages/Health-Equity-Data

Maryland Chartbook of Minority Health And Minority Health Disparities DataSelected Statewide and Dorchester County Data - February 15, 2011

Chronic Disease SHIP Metrics: Mid-Shore (August 2012)http://www.dhmh.maryland.gov/mhhd/Documents/MidShore%20Maryland%20Jurisdiction%20Level%20SHIP%20Disparity%20Charts%202012%2008%2016%20Final%20(1).pdf

7/20/2017

77

Ashyrra C. [email protected]

410 – 221- 0795

153

Health Systems Integration with Primary Care

Angela Mercier and Miranda LeCompte

Dorchester County Health Department

Office [3]1

Office [3]1 Need slides from DorchesterMicrosoft Office User, 7/13/2017

7/20/2017

78

Dorchester County Health Department Health Systems Presentation

MDH Center for Chronic Disease Prevention and Control’sCDC 1422 Grant Site Visit

July 20, 2017

Caucasian 65%

American Indian 0.3%

African American 29%

Asian/Pacific Islander 1%

Hispanic 5%

DORCHESTER COUNTY POPULATION BY RACEMARYLAND VITAL STATISTICS ANNUAL REPORT 2015

Total Population: 32,384

7/20/2017

79

Birth - 4

Age 5 - 14

Age 15 - 19

Age 20 - 44

Age 45 - 64

Age 65 - 74

Age 75 +

DORCHESTER COUNTY POPULATION BY AGEMARYLAND VITAL STATISTICS ANNUAL REPORT 2015

Total Population: 32,384

▪ 57% between age 20-64

▪ 11% age 65 and above

▪ 23% age 19 and under

Dorchester County Overview County Health Rankings & Roadmaps (2017)

Health Outcomes – Rank 23rd Health Factors – Rank 22nd

Length and Quality of Life Health Behaviors, Clinical Care, Socioeconomic Factors, and

Physical Environment

7/20/2017

80

County Health Rankings & Roadmaps Data (2017)

Dorchester County Maryland

Diabetes Prevalence 16% 10%

Adult Obesity 36% 29%

Physical Inactivity 30% 22%

Unemployment 7.4% 5.2%

Children in Poverty 30% 14%

Primary Care Physicians 2,510:1 1,130:1

Dentists 1,900:1 1,350:1

Choptank Community Health SystemFederally Qualified Health Center

Private, non-profit community health center

Provides primary and oral health care in Caroline, Dorchester, and Talbot Counties

Care Coordinators, Community Support Specialists, etc. provide wraparound services

Implementing interventions to improve quality of health care delivery to populations with highest hypertension and prediabetes disparities

7/20/2017

81

Partnership with Choptank Community HealthAddressing chronic disease burden

▪ Dedicated leadership and staff▪ Medical Director

▪ VP Quality Assurance / Director of Population Health

▪ Care Coordinator

▪ Monthly conference calls to enhance efforts▪ Share updates

▪ Review progress

▪ Identify gaps

▪ Problem solve and brainstorm ideas

DPP ChampionsRecruit and refer patients

▪ Use ICD-10 codes for prediabetes and pre-hypertension

▪ Integrate measurement, assessment, and referral into office visits (including dental)

▪ Encouraged universal DPP referral form for all partners

▪ Utilize Wellcentive, population health management tool/platform to identify participants

▪ Educated and empowered ALL staff to speak same DPP language

7/20/2017

82

“Commit to Be Fit” ChampionsBlood pressure control efforts

▪ Comprehensive physical activity and nutrition campaign in Dorchester County

▪ Choptank promotes actively in their clinic

▪ Instituted in clinical care and individualized care plans

▪ Distributed BP cuffs to eligible patients

▪ Flagged charts to remind patients to bring BP logs

▪ Building culture of patient empowerment

Oral Health CollaborationsClosing loop back to primary care

▪ Dental clinic co-located at Fassett Magee

▪ Protocol for dental patients in Stage 2 Hypertension▪ Medical triage nurse contacted to assess patient

▪ Dental provider consults with PCP to determine action plan

▪ Dorchester County Health Department also working with three additional oral health practices▪ Dr. Hyun Bae, Dr. Jean Carlson, and Harbor Dental Center

▪ Implement BP measurements and system level changes to identify and treat undiagnosed hypertension

▪ Plan to refer patients to Choptank or PCP if in of need medical care

7/20/2017

83

Partnership with UMES School of PharmacyCommunity clinical linkages

▪ Strengthened relationship between pharmacy and PCPs

▪ UMES students on 5-week rotations in two local pharmacies (Craig’s Drug Store in Cambridge and The Drug Store in Hurlock)

▪ Also distributed BP cuffs to eligible patients

▪ Walk-in measurements and assessments for hypertension and prediabetes

▪ Communicate via fax/secured email re: BP readings, new patient w/o PCP, request dr. appointment

Next StepsDelving deeper into oral health collaborations

Monitoring workflow to increase referralsFurther enhancing linkages

7/20/2017

84

Angela MercierHealth Education Program Manager

[email protected]

Miranda LeCompteChronic Disease Prevention Coordinator

[email protected]

Contact Information:

Dorchester County Health Department3 Cedar Street

Cambridge, MD 21613

Field Visit: Highlights from Local Programs · 2019-02-19 · 7/20/2017 1 Field Visit: Highlights...

Documents

Transcript of Field Visit: Highlights from Local Programs · 2019-02-19 · 7/20/2017 1 Field Visit: Highlights...